Surgery Block 4 Flashcards
What are the 3 parts of the Trimodal Death distribution and injuries in each
Sec-Min:
Intracranial injuries
Transected vessels
Min-Hrs: Sub/Epidural hematoma Hemorrhage Organ lacs Pelvic Fx Hemo/Pneumo Thx
Day-Wks:
Sepsis, MODS
How is medical control of the prehospital phase ensured?
What are the first two steps before the four steps of Field Triage?
Protocol trauma
Comms w/ Physician
Subsequent trips
VS, LoC
PTs who fall into ‘Immediate’ Triage means ?
What types of injuries would place PTs in this category?
Outcome depends on immediate interventions
Hemorrhage Airway obstruction Tension PTx Retrobulbar hematoma Amputation Blunt/penetration w/ shock Intracranial hemorrhage Threatened limb loss
Four priority steps of ‘Immediate’ management
‘Delayed’ category of Triage means ?
What types of injuries does this category encompass?
Bleeding
Airway/ventilate
Circulation
Wounded but stable
FacialFx/injury w/ airway Non-life threatening burns Globe injuries Blunt/penetrate, no shock Larger lacerations Stable VS
What PTs may fall into the Minimal Triage category
Why are PTs in minimal category so dangerous?
What PTs may fall into the Expectant Triage category
Self care until Evac:
Minor lac/burn
Small bone Fxs
Overwhelm MassCas resources d/t bypassing MedEvac, self report
No VS on arrival Shock Head gunshot w/ coma Severe burns High spinal cord injury
Secondary survey’s start at ? and work ?
What are the two most rapid methods that PTs die from?
HEENT
Clavicles down
Loss of airway
Bleed: SBP <90+HR>130
Initial circulation check includes ?
By palpating BP on ? three locations can give BP estimates of ?
Pulse LoC Skin perfusion
Radial >80
Femoral >70
Carotid >60
What two parts of circulation exam give the PTs hemodynamic status?
Initial fluid resuscitation includes ? followed by ? empiric blood products
What are 3 types of injured PTs that would need this type of fluid resuscitation
LoC
Skin perfusion
1L isotonic crystalloid
1:1:1- PRBC Plasma Platelet
Complex pelvic Fx
US w/ Intraperitoneal blood
Bilateral femur Fx
Why does excess administration of crystalloids need to be avoided in trauma?
What type of blood bank order should be placed and ready w/in ?
What part of the disability assessment is the most predictive for the PT?
Exacerbates vicious triad: hypothermia acidosis coagulopathy
Type specific in 20min
Best motor score
PT w/ lateral gaze and dilated pupil means ?
Normal sizes should be within ? of each other and dilate more than ?
Stem herniation through tentorium cerebelli
1mm
>4mm
What are the parts of a 9 Line report
1: location
2: frequency
3: PT type
4: special equipment
5: PTs by type
6: security at scene
7: mark of LZ
8: nationality/status
9: NBC threat
The secondary survey may begin when and used ? acronym
What are the 3 priorities of the secondary survey
What is the MC error of the secondary survey
Primary survey complete
Resuscitation underway
Hemodynamic stable
AMPLE
ID all wounds
Need for urgent surgery/further tests
Failed ID of multi-injuries
Secondary survey decision making process is driven by what two factors?
Resuscitation efforts do not focus on normal VS but instead focus on ?
Hemodynamic stability
Location of wounds
Blood products
IV access
Transport to OR
? is the most valuable test of penetrating trauma
What are the indications to perform an urgent thoracotomy?
Determine trajectory w/ x-ray
> 1500 initial output
200/hr x 3hrs
Hemothorax w/ 2 tubes
? is the most reliable screening for intrathoracic and intra-abdominal bleeds?
What part of the body is more likely to conceal an occult bleed after blunt trauma?
Chest: CXR
Abdomen: fast
Abdomen
How much blood can the peritoneal cavity hold w/ possibly minimal distension?
Unstable pelvic trauma PTs w/ positive US need ? procedure
If there is no evidence of bleeding but PT remains unstable, what is the next Dx considered
3L
Laparaotomy
External pelvic fixation and pelvic packing
Angioembolization
? PT presentation after blunt trauma indicates need for emergency craniotomy
If hemodynamically stable obtain ? image
GCS <9
Lateralizing neuro exam
CT- dx tool of choice for suspected head injuries
Closed head trauma is rarely the cause of HOTN except ?
What is the gold standard initial screening tool for blunt trauma CVIs?
Final phase before herniation
Spinal cord injury association
CTA of neck
What blunt trauma chest injuries are ruled out during the secondary survey?
What injury needs to be r/o if PT has Fx of first rib
Pulmonary contusion
Blunt trauma to RV/Aorta
Rib Fx
Blunt cardiac injury
Apical tumor S/Sxs
Pt w/ flail chest and pulmonary contusions needs ? early intervention
What is the MC location of blunt aorta injuries to occur?
What may be seen on CXR indicating injury presence?
Intubation
Distal to L SCA take off
Mediastinum >8cm
Apical cap
Any PT w/ mechanisms suspicious for aortic injury needs ?
What happens to PTs w/ blunt trauma after FAST exam
? is the MC injured GU organ, what is the most reliable sign of this injury, and what is the first line image ordered
CT angiogram
+ FAST and unstable: OR
+ FAST and stable: CT w/ contrast
Renal injuries
Hematuria
CT
How are renal injury PTs managed post-op?
? organ damage is highly probable w/ pelvic Fx
Perform ? procedure prior to cannulation
Bed rest until clear urine
Foley cath until PT controls urge
F/u CT 48-72hrs
Bladder
Cystogram
What does an extended FAST include?
What does subcutaneous emphysema look like on CXR
Eval for Hemo/Pneumo thorax
Comb like, striated appearance
Where do subpulmonic effusion develop?
What would be fiver terms used to describe their appearance
Between visceral pleura and diaphragm
Blunting angles
Meniscus
Opacified hemithorax
Loculated
Define Fissural Pseudotumors
These are usually associated with ?
MC- Fluid trapped between minor fissure layers
CHF
Define Laminar Effusions
Define Hydropneumothorax
Density on lateral chest wall near angles
HemoPneumo- air and fluid
Three foramen in diaphragm allow for passage of ?
Diaphragm injuries are usually seen on ? side after inserting ?
How are these injuries Tx
Vena cava
Esophagus
Aorta
L side, NG tube
Transabdominal surgery
Ascending aorta usually doesn’t go farther R than ?
Aortic dissections MC originate ?
RA border
Stanford A, ascending aorta
What C-spine image may be used for starting?
What are normal spaces in the C-spine that alterations would indicate soft tissue edema
Loss of lordotic curve on lateral c-spine images indicates?
Lateral
C2- 6mm
C6- 22mm
Tissue swelling
Muscle spasms
Hangman Fx
When are these considered stable and how are they Tx
Traumatic spondylolisthesis:
Axial compression and hyperextension= bilateral pars Fxs
W/out C2-3 angulation
Philadelphia collar/SOMI brace x 12wks
Jefferson Fx
Since most of these don’t present as isolated Fx, what else is usually present?
Atlas Fx from axial loading, usually w/out neuro injury
C2/Axis Fx
Clay Shoveler’s Fx
How are these Tx
C7 spinous process fx w/ unilateral lamina/pedicle Fx
Rigid cervical collar
Hyperflexion injuries are usually ? injuries
How does these change once classified as Tear Drop Fx
Flexion and distraction
Severe hyperflexion w/ posterior displacement
PTs usually quadriplegic
Hyperextension injuries are usually ? types of injuries
Most of the time PTs will have ? neuro Sxs
Bilaminar Fxs can be accompanied w/ ?
Extension and compression- forehead blow Fx posterior complex
Radiculopathy
Complete cord lesion
Bilateral vertebral arch Fxs are yperextension injuries that have complete ? translation of vertebral body
These PTs can present w/ one of what 3 issues
What do they rarely have?
Anterior
Radiulopathy
Central cord syndrome
Incomplete cord lesion
Complete cord lesion
What part of C2 is MC Fx
What are the 3 types
Odontoid
Type 1: tip
Type 2: neck, ground level fall in elderly PTs
Type 3: junction of process and body
Why do most PTs not survive AOD injuries
When would this Dx be changed to AAD?
Brain stem injury, respiratory arrest
Prevertebral swelling on x-ray
CT of SAH at craniovertebral junction
Where do most Fxs of lumbar spine occur
What are the 3 parts of the Denis three column principle here
T12-L1 junction
Anterior
Posterior
Intertransverse ligament
What are the four major types of thoracolumbar spine injuries?
Compression Fx
Burst Fx
Chance fx
Fracture-dislocations
What is the criteria for an L-spine compression Fx
How are these Tx
What if the risk if the criteria is not met and exceeded?
<50% loss of height
<30% angulation
Intact posterior column
Analgesic
Bed rest
> 50% height loss- inc risk for kyphosis
Define L-spine Burst Fx
What are the indications these need surgical correction?
Unstable Fx even if no neuro Sxs, avoid early ambulation
> 50% loss of height
Canal narrowing >50%
Kyphotic angle >25*
L-spine transverse Fxs are normally ? and best assessed via ?
Define Young-Burgess Classifications for pelvic Fx
Define AO Tile Classifications
Stable
AP x-ray view
Force of vectors causing Fx
Degree of in/stability
What are the three categories of Young-Burgess Fxs
What are the 3 AO-tile classifications
Lateral
Anteroposterior
Vertical force
A: ring intact
B: rotation unstable, vertically stable
C: ant/posterior instability
Most PTs w/ femoral neck Fx present looking like ?
What is the sequence for evaluating abdominal x-rays
Short, external rotation and abducted
Gas pattern
Extraluminal air
Calcifications
Soft tissue masses
What x-ray findings indicate the spleen is enlarged?
Hemodynamically stable PT w/ positive FAST gets ? imaging and ? procedure
Protrudes below 12th rib
Pushed gastric bubble past midline
CT w/ contrast
Extravasation= hollow viscous injury, exploratory laparotomy
PTs w/ abdominal trauma causing solid organ injury w/ evidence of bleeding should have ? considered
This adjunct when done early is good for managing ? injuries
Angiography
Liver, Spleen, Kidney injuries
Extremity x-rays are always taken on what two planes?
When do these x-rays need to be repeated?
AP and Lat
After reduction
? is the image of choice for detecting intracranial bleeds
What are the 4 areas these bleeds can occur or accumulate
HT CT
Subarachnoid
Epi/Subdural
Prenchyma
What is the initial step when Tx TPs w/ blunt thoracic trauma?
What types of chest wall injuries have to be Tx w/ surgery
Airway management
Penetration w/ >1L blood loss
Diaphragm rupture
Aortic transection
Cardiac tamponade
? is the initial imaging ordered for chest wall injuries
? is the MC chest wall injury from blunt trauma
Portable CXR
Rib Fx
How are PTs w/ flail chest and unable to cough Tx
When do these PTs need to be intubated
Pulmonary toilet
Dec pulm function w/ worsening hypoxia/hypercarbia w/ adequate pain control
How are PTx Dx w/ CXR
When are these categorized as occult?
How are these occult ones Tx
Exhalation
PTx on CT but not seen on CXR
Observed
What are 3 possible complications to arise from hemothorax Tx
What image may be ordered to help show size and location?
Atelectasis
Empyema
Retained hemothorax
Thoracic CT
Pulmonary contusions causes the systemic activation of ?
What imaging is best for visualization and assessment?
These injuries are well known RFs for PTs to develop ?
Innate immunity- release of interleukins, prostaglandins and chemokines
Chest CT
Pneumonia
Sepsis
Chylothorax development is more likely to develop after ? but rarely after ?
If rarely develops, what causes it
Common- iatrogenic
Rare- trauma
Axial chest injury
Spine Fx
How are chylothoraxes Dx
These can often drain more than ? per day and be considered normal
How are chylothoraxes Tx
Chylomicrons and Inc Tg in pleural effusion w/ milky white appearance
1L/day
Dec/stop Tg intakes
Surgery if Tx failure
Most PTs don’t survive aortic transections unless ? structure holds?
? is the gold standard imaging for great vessel injury from penetrating trauma
How are these injuries usually exposed during Tx
Adventitia
CT angiography
Median sternotomy
What is the MC location for the heart to be injured from trauma?
What PE finding may occur w/ Beck’s Triad but is rarely detectable
RV
Pulsus paradoxus
What is the first imaging test conducted on PTs w/ high risk chest penetration wounds?
What is the next step for PTs w/ obvious cardiac tamponade and not in immediate arrest?
What is the next step if PT has risk factors?
FAST
OR for sternotomy
EKG
Abormal EKG= Echo
What are the immediate steps taken for PTs w/ cardiac arrest from pericardial tamponade?
When are resuscitative thoracotomys best for blunt or penetrating trauma?
PT must have ? to even consider this Tx
Thoracotomy w/ pericardiotomy
Penetrating: CPR <15min
Blunt: CPR <10min
Organized rhythm, even PEA
When performing resuscitative thoracotomy, what caution needs to be taken?
What types of airway disruptions can create the need for this procedure
Phrenic nerve on posterior side of heart
Pulmonary lac w/ hemorrhage
Hilar twist
Staple wedge resection
Why would delayed exploration of the chest need to be conducted
What are the two approaches to conducting delayed exploration of the chest?
If both sides of the chest need to be opened, what type of procedure can be converted for the need?
Hemorrhage, small/missed
Empyema post trauma
Retained hemothorax
Medial sternotomy
Posterolateral thoracotomy at 4-5th ICS
Post-Lat to Bilateral Clamshell
What are the two relative c/is for doing a chest thoracotomy?
What are the 3 maneuvers conducted to prevent bleeding complications?
Blood dyscrasia
Anticoagulation
Enter pleura above rib, avoid neurovascular bundle
360* finger sweep
Controlled pleural entry
What are the borders of the triangle of safety for a thoracotomy procedure?
Where is the insertion site marked on the PT
Medial: pec muscle
Lat: lat dorsi
Inferior: 4-5th ICS
5th rib AAL in triangle/
How many applications of sterile solution are applied prior to a thoracotomy
What are used for drapes/coverings?
3 in circular motion
Fenestrated
3-4 towel technique
What is the best location for a closed thoracostomy tube
What material is used to suture tube in place?
5/6th ICS anterior mid-axillary line
0 or 1 silk
How much water is placed in a pleur vac suction chamber?
How much water is placed in the air leak meter?
20cm
2cm
What pleur vac indication means there is an air leak?
How is post-placement CXR verified
How far into chest does tube go?
Leak meter bubbles and doesn’t settle after 1min
Last fenestration in chest w/ radiopaque break in line
Hugs wall up to apex
Initial setting for chest tube maintenance is on ?
What happens if this setting is inappropriately shifted to wall suction?
Water seal then low wall suction 1-2hrs after insertion
Pulm edema refractory to diuretics
How much fluid is produced by the lung and pushed through the chest tube?
What are 3 chest tube maintenance checks done every day?
100-150ml/day
Air leak check
Drainage check
CXR
What is the acronym for trouble shooting chest tubes?
What is done if an air leak is identified
DOPE- Displaced Obstructed Position Equipment failure
Check vac connection tube
Check insertion site
Both ok= lung injury etiology
When are chest tube removals considered?
What does PT need to do during extraction?
No air leak in water seal
<200ml drained x 24hrs
No PTx
Hum
? organs are in the anterior abdomen?
What organs are in the retroperitoneum
Liver Spleen Transverse colon Small intestine
Duodenum Pancreas Kidney Aorta Vena cava
? hollow organ is MC injured in blunt trauma?
Dx laparoscopy is performed on ? PTs to establish ?
What are the 3 main indication to perform a laparotomy?
Duodenum- posterior located pressed against solid structure
Stable w/ penetrating trauma
Peritoneal penetration or not
Peritonitis
Intra abdominal hemorrhage
Presence of injuries
? Dx is rare after blunt abdominal trauma
Absence or presence of bowel sounds during abdominal trauma HnP means ?
Peritonitis
Presence- doesn’t r/o intra-abdominal injury
Absence- does not prove intra-abdominal injury
What type of abdominal trauma can cause ileus
During percussion the abdomen, dullness can indicate ? while hyper tympany can mean ?
Hypovolemia TPTx Tamponade Peritonitis Lumbar spine injury
Intraperitoneal bleed
Intraperitoneal air
What labs are ordered during abdominal trauma?
What are the limitations of CT in abdominal/pelvic trauma assessments?
CBC CMP UA
Amylase/Lipase if pancreas injury suspected
Miss hollow viscous injury
Fat stranding
Pneuoperitoneum
Free fluid
? PE finding doubles relative risk for PT to have small bowel injury
Pts w/ ? types of Fx need to have hollow viscous injury suspected?
Seat belt sign
Chance Fxs
What are 3 lab abnormalities that may point towards presence of hollow viscous injuries?
GSWs to abdomen get ? procedure
? is the exception to this rule
Inc WBC
Amylase
Lactic acid
Exploratory laparotomy
Tangential wound- laparoscopy, peritoneum violation turns into laparotomy
? have a lower incidence for intra-abdominal injury than GSWs
PTs w/ eviscerations have ? procedure
Stab wounds
Laparotomy
How are blunt trauma PTs need for surgery assessed?
No hemorrhage- Monitor, non-op Tx w/ serial exam/images
+ hemorrhage- monitor if stable, preferred for Peds
Unstable, usually d/t liver/spleen- OR
3 true facts about blunt injuries to abdomen
What is a false fact?
? is the MC organ injured during blunt trauma
Cause duodenum hematoma
Causes more diaphragm injuries than penetrating
Can rupture hollow viscus
All need to be explored
Liver
What are indications to repeat imaging for ASx liver trauma PTs
When do these injuries need to be re-imaged prior to return of sports?
Grade 4 or higher w/ US
Grade 4-5: repeat CT
4-8wks after injury
3mon prior to sports
How are spleen injuries managed?
PT w/ abdominal trauma, air around kidney w/ RLQ crepitus means ? structure is injured
HOTN/Peritonitis- laparotomy
Stable- eval w/ CT
GSW- laparotomy
+ FAST + HOTN- laporotomy
Duodenum
What may be see on x-ray after duodenal/pancreatic trauma
When/why would repeat images be needed
Intra/Retroperitoneal air
Obliterated psoas shadow
Initial negative CT but high suspicion remains
What is the first step taken for suspected pelvis Fx
Why are these steps taken?
Splint/sheet wrap
Wrap legs together
Reduce intrapelvic volume
Leg wrap= internal rotation
What is done to determine if pelvic Fx blood is venous or arterial?
What is the next step if artery is source?
What is the next step if venous source?
Contrast CT
Antiographic embolization
External fixation
ACS causes ? to occur in the PT?
If abdomen is closed, what needs to be monitored?
Inc peak airway pressure and vascular resistance
Dec CO
Acidosis
Inc lactate
Dec urine output
What are two types of drains may be used for abdominal/pelvic trauma during post-op care
Jackson Pratt- grenade shaped vacuum system under pressure
Penrose- prevents wound healing and allows seroud drainage; open and not under suction
Define Consciousness
What are the two parts
Subjective experience of environment and self
Arousal- wakefullness
Awareness- phenomenal perception
? defines the level of consciousness
Define awareness
Arousal response
Defines content of consciousness
Define Alert
Define Stupor
Define Obtunded
Define Vegetative
Define Comatose
Awake, responds to stimuli
Less alert, responds to stimulation
Appears asleep, responds to noxious stimuli
Arousal w/out awareness
No response to stimuli
Why does excessive cauterizing scalp bleeds need to be avoided
Scalp lacs are repaired in at most ? layers
Never use ? if a scalp Fx is present
Hair follicles in galea, can lead to alopecia
2
Active drain
What are the layers of the scalp from out to in
What is a secondary brain injury that needs to be prevented
Skin CT Aponeurosa Loose tissue Pericranium
Hyperglycemia
How often is a PTs need for artificial airway re-evaluated?
When do they need to be intubated?
5min
GCS 8 or lower Motor of 4 or lower Lost protective reflexes Ventilatory insufficiency: PaO2 <60 PaCO2 >45 Spot Hyperventilate PaCO2 <26 Respiratory arrhythmia
What are the two worse secondary insults following a TBI
Severe O2 desaturation is categorized below ? and inc mortality x3
Hypoxia
HOTN
<60%
What are sings PT is suffering from hypoxia
What PE tool can be used to indicate an adequate MAP pressure
Confuse Delerium Agitation
Coma
Peripheral constriction
Tachy/Tachy
Radial pulses
Dec in MAP causes a dec in ?
MAP equation
How does this correlate if BP is 90/60
CPP
MAP= 1/3 (SBP + 2DBP)
1/3(90+120)= 70
Equation for CPP
How is CPP measured
MAP - ICP
Centriculostomy placed by neurosurg
Define Intracranial HTN
Where are ICP monitor bolts placed?
When are these placements indicated?
Inc pressure in cranium
Epi/Subdural
Intra-parenchymal
Intraventricular
GCS 8 or greater and abnormal head CT
GCS scores
14-15: normal/mild
9-13: moderate
3-8: severe
E- 4
V- 5
M- 6
Define Hyphema
Discovery on this during trauma exam can indicate ?
Blood pooling in anterior chamber
TBI sign
What are two things that could cause pupils to be constricted?
What labs are ordered for decreased LoC
Narcotics
Organophosphates
CBC Coag E+s ABG Tox screen Blood/CSF cultures Thyroid function/B2/Cortisol- suspected endocrinopathy
Acute ischemic strokes w/in first ?hrs can be occult on CT images
When would an MRI be warranted
3-4hrs
Characterize neoplastic lesion
Assess ischemic strokes
Why would an EEG be ordered for Dec LoC?
Only order these after ?
Confirm global cerebral dysfunction
Exclude status epilepticus
Structural lesions have been excluded
What does cerebral edema look like on CT images?
What does a midline shift mean and what wold be seen on PE?
What are the next steps done for these PTs?
Loss of grey/white differentiation
Herniated brainstem
Ipsilateral dilation, contra motor issues
Prevent HOTN, Hypoxia
Tx elevated ICP
Subdural hematomas are due to ? and present in ? PTs
Epidural hematomas are due to ? injury and have ?
Ruptured vein in elderly PT
Middle meningeal artery trauma w/ lucid interval
Define DAI
How do PTs present
Diffuse axon injury from shearing from accel/decell injury
Normal CT, shift or hematomas
What is our BP goal during ICP
Why is this the target goal
What drug can be pushed to help manage shock?
SBP >90
Keeps MAP >70 and ICP <20
Phenylephrine
What fluid is used for resuscitation during elevated ICP
Why would hypertonic saline be used?
How is this type of fluid not given?
NS until SBP >90 or palpable radial pulse
Max expansion, minimal volume
Not through peripheral IV
How much mannitol is used during elevated ICP
What serial measurements need to be done on these PTs
0.25-0.5g/kg x 10-15min
Serum Na/osmolality
Renal funciton
What drug combo is pushed for PTs w/ elevated ICP induced agitation
What med is used for an anti-seizure prophylaxis
What meds are reserved for refractory cases?
What is the last resort
Propofol + Fentanyl
Levetiracetam x 7 days
Barbituates
Decompressive craniectomy
What is the MC complication for PTs after TBIs?
What E+ do TBI PTs tend to be low on and why?
Seizures
Na-
Cerebral salt wasting
SIADH
What does Cerebral Salt Wasting occur after TBIs
What is the safest and most prudent Tx strategy for PTs w/ severe TBIs
Release of BNP
Euvolemia
What are the 4 types of neurosurgical interventions for elevated ICP removal
What is the ICP goal for these procedures
Ventriculostomy
CSF drain
Decrompressive craniectomy
Barbituate metabolic coma
<20mmHg
How do PTs w/ elevated ICP and brainstem herniations present
PTs w/ Tonsillar herniation classically present w/ ? Triad
Dilated, unresponsive pupil w/ lateral gaze- CN3 pressure from uncal herniation
Cushings Triad:
Inc SBP/wide pulse pressure
Bradycardia
Irregular respiratory pattern
PTs w/ low GCS and ? PE finding is concerning for increased ICP?
If hyperventilation efforts are used to dec ICP, what are the capnography pCO2 goal ranges?
Why are these ranges needed?
Bradycardia
Normal resp: 35-45
Hyper vent: 26-30
Too much hyperventilation dec CPP to brain ischemia
What are the 3 sequential stages of wound healing
What steps occur in each
Inflammation
Migration/proliferation
Maturation
Inflammation- constriction, coagulation to stasis
Prolongation causes abnormal healing
M/P- epithelialization in 24-48hrs, wound contraction
Mature: final phase, remodeling
How long does it take for wound healing to reach 80% of original tensile strength
What are the 3 types of wound closure
6-8wks
Primary: suture/staple <8hrs from injury
Secondary: self heals, pack to allow healing from in to out
Tertiary: delayed primary, allows debridement
What are the 5 steps to acute wound management
Define Contusion
Stop bleeds Debridement Clean w/ saline Examine depth/width Close
Initial Bedside exam Anesthesia Examine wound Determine closure
Superficial wound w/ intact skin
Define Abrasion
If left to heal by secondary intention, how long does this take?
What is done if wound is weeping proteinaceous fluids
Superficial damage to epi/dermis from friction
7-14days
Remove pseudoeschar
What is the result if abrasions are not debrided in <48hrs of injury
Why are these types of injuries so painful
Traumatic tattooing
Exposed cutaneous nerves
Term ‘laceration’ indicated ? tissue is damaged?
How long can these left open before they need to be closed
How are these prepared for healing if contaminated and why
6-8hrs
Face- <24hrs
Secondary intent- hematoma, necrosis or foreign body creates barrier to tissues
How are crush injuries examined w/ images
These PTs need to be monitored for ?
US or MRI to eval for hematomas
Compartment syndrome- 6 Ps
Suspected compartment syndromes need ? measurement taken
What result is positive
If Sxs persist, fasciotomies need to be performed w/in ?
Intracompartment mental pressure
> 30= + compartment syndrome
<6hrs
Compartment syndrome can lead to ? two issues
What is initiated in these PTs as prophylaxis against HyperK
Rhabdo
Renal failure
Forced mannitol-alkaline diuresis
What can cause extravasation injuries
Presence of ? RFs can indicate a more serious effect
Fluids in interstitial space
Occluded vessel
Dislodged catheter
High fluid volume
High osmolar contrast agent
Chemo agents
Cause ulceration/necrosis
Extravasation Txs depend on ?
How are these Tx
Substance involved
Time of detection
Degree of damage
InD/ Aspiration
Graft/Flap coverage
Bites over joints need to heal by ?
What prophylaxis is added for animal bites?
What ABX is added for human bites
Secondary intention/delayed primary closure
Rabies
Augmentin
What snaked belong to elapids?
What type of toxin do they have that cause ?
Cobra
Mambas
Neurotoxic- cardio/pulm manifestations
What snakes belong to Vipers
What type of venom do they have and that cause ?
Rattlers, Vipers
Cytotoxic- necrosis, hemolysis, compartment syndrome
What two factors provide the best chance at optimal function after amputations
What are the 3 steps of primary closure
Bone length
Joint function
Pain control
Debride
Irrigate
When are wounds allowed to heal through secondary intention?
How does wound closure happen by secondary closure?
Concern for contamination/infection
Granulation
Contraction
Epithelialization
How are narrow punctures allowed to heal
How do wound vacs promote healing
Secondary intent w/ packing and daily changes
Stimulates fibroblast repair activity
What Tx step may be attempted on surgical site infections?
Chronic wounds are usually seen in ? PT populations and due to ?
Wound vacs
DM, Obese
Malnutrition ImmSupp Infection
What is the main factor leading to delayed wound healing?
How are decubis ulcers allowed to heal
Profound inflammatory state
Primary closure
Foam dressings are best for ?
Alginate dressings are best for ?
Debridement dressings are best for ?
Absorbancy
Comfort
Debridement
What are the 5 types of dressings for chronic wounds and what are the advantages/disadvantages of each
Simple: debridement, pain
Film: water resistant/not for grossly infected
Alginate: exudate, confused w/ slough
Foam: minimal pain, no monitoring
Hydrocolloid: little pain, not for grossly infected
Hydrogel: clears necrotic tissue, must use w/ secondary dressing
What type of dressing can be used that has no absorption capacity w/ little hydrating ability?
After controlling infection, debridement and pressure of chronic wounds, signs of healing should show in ?
What is done if this time limit is not met
Transparent film
2wks
Quantitative bacterial wound culture w/ topical antimicrobials
Define BMZ
What does this connect
Why is this layer important in burn healing?
Region of extracellular matrix
Basal cells of epidermis to papillary dermis via rete ridges
Protect from shearing forces during healing process
What are the 3 zones of injury from burns
Central: most severe, coagulation, must be debrided
Stasis: constriction, ischemia, viable, may convert to coagulation
Hyperemia: dialation, viable
Why do full thickness/3rd degree burns need surgical closure?
What type of burn is not applicable to Rule of 9s
No hair follicles prevents repopulation of new karetinocytes
First degree
How are First Degree burns Tx
How do Second Degree appear?
Acetaminophen/NSAIDs Hydrating lotion (not alcohol)
Extend into papillary dermis w/ hallmark of blistering
What are the two categories of Second Degree burns?
Superficial partial thickness- pink, moist, painful, heals w/out scar
Deep partial thickness- extends into reticular layer, pink/white, dry and variable pain
Heal w/ scar/contraction
If partial thickness burn is not healed w/in ?wks ? is needed
What do Third Degree burns look like?
3wks, surgical excision and grafting
Through dermis in SQ
White/black and painless
Distinguished from superficial- NOT moist, no blanching
How are Third Degree burns Tx
What is the critical time piece to this Tx
Excision and grafting, only heal by contraction of keratinocytes
Removal of eschar
Superficial partial/second degree burns can be Tx w/ occlusive dressings to minimize exposure except for ?
What types of burns need topical ABX applied to them?
Face- Tx open w/ antibacterial ointment
Deep second degree
Third degree
? Tx has no role in the management of acute burn wounds?
Why is this
Systemic ABX prophylaxis
Eschar has no microcirculation
? med is the MC used for partial/full thickness burns?
What s/e may be seen?
SIlver sulfadiazine
Transient leukopenia
What type of pain meds are preferred during debridement?
What imms needs to be given?
PT presents w/ 3rd degree burn after 8 days and is systematic, what is the best Tx step
IV
Tetanus
Remove burned skin, apply sodium mafenide
How often are burn dressings changed?
What position are they splinted in
24-48hrs
Position of function
What are the 3 types of skin grafts that can be done for burns?
What is the benefit of a full thickness graft
What are 3 locations this is used on?
Auto- from PT
Allo- same species
Xeno- other species
Full thickness of dermis, better cosmetic/function
Face Neck Hands
When/where is a split thickness graft used for?
What benefit does this type of graft allow?
Meshed graft of healthy skin from donor site
Egress of serum/blood from wounds
Greatest loss of fluid and protein from burns occurs in first ? hrs but capillary integrity can return w/in ? hrs
What causes the edema to develop?
6-8hrs
36-48hrs
Hypoproteinemia
? type of burn Pt may have an increased instability of hemodynamics?
What fluid issues are unique to burn PTs
What happens as plasma volume is depleted?
Smoke inhalation
Edema
Fluid shifts
Inc capillary permeability
Inc extracellular fluid
Intravascular hypovolemia
What are the two formulas used for fluid replacement in burn victims
What is the equation
What is the first fluid used?
Baxter/Parkland formula
4ml x TBSA x Kg
1/2 fluid in first 8hrs, rest over 16hrs
Initially- LR
While delivering fluids via Baxter equation, PTs are at risk for developing ? and may require ?
What is the targeted range for UOP in these PTs?
AKI, vasopressors
0.5ml/kg/hr
What procedure is performed to relive circumferential burns?
Burns cause bodies to enter hypermetabolism and increase the secretions of ?
Escharotomy
Catecholamines Cortisol Glucagon Renin-angiotensin ADH Aldosterone
What effects increase the body’s obligatory hypermetabolism reflex after burn injuries
How long does the hypermetabolic reaction last
What meds can be used to decrease this response
Pain
Cooling
Sepsis syndrome
7d
BB- dec catabolism
Insulin GH Testosterone analogue- dec catabolism, increase anabolism
Burns that heal in position of comfort and not function are corrected w/ ?
What are the 3 types of electrical burns?
Z-plasty
Current
Thermal from arcing
Flame
How are electrical burn PTs Tx
How are cord biting injuries Tx
Admit- burn unit
Cardiac monitor d/t cell damage leaking K+
Fluids/Serial long bone eval
Splint to avoid contracture
Reconstruct after healing
Acid burns cause ?
Alkaline burns cause ?
? is one of the MC causes of hospital associated infections
Coagulation necrosis
Liquefaction necrosis
Post-op infections
What are the 3 factors that determine the infectious process
? are a more important cause of SSI than exogenous bacteria
Organism
Environment
Host defense mechanisms
Endogenous
What are the most frequently pathogenic bacteria in surgical PTs
? is the MC encountered enterococcal species
What is the MC species encountered that is Vancomycin resistant
Gram + Cocci: Staph A Strepto Enterococcus
Gram - Bacilli: Pseudomonas E Coli
E faecalis
E faecium
Pre-op hand wash includes washing all four surfaces of each finger ? times
If become contaminated in OR, who removes/reapplies gear
20
Circ: removes glove
Scrub: regloves
Sleeve: scrub
Circ: removes gown
Scrub: re-gown
Define Avagard
When can this be done
How is this done?
Pre-surg scrub done in lieu of full scub ir:
Full surgical scrub done for first case
No departure of the OR
No bathroom/eat/smoke break
One pump on hand
One pump on arm, wrist to elbow
PTs w/ US confirmed hemopericardium and tamponade go to OR for ? procedure
What is a temporary measure done for these PTs that is not a definitive Tx
Sternotomy
Pericardiocentesis
PTs w/ persistent signs of pericardial tamponade, tachy and JVD, but a normal sonogram go to OR for ?
What temporary procedure is done if PT doesn’t make it to OR
Subxyphoid window
Resuscitative thoracotomy
What CT results indicate possible hollow viscus injury in abdomen?
What is the next step after these findings?
Free fluid
Mesenteric/boewl wall thickening
Serial PEs
Amylase level checks
Topical ABX
Sequence of primary closure
Contracture AKA ?
Deep partial/3rd burn
Chronic wound
Face
pain clean irrigate
Stricture
What burn PTs need pain meds
1st 2nd Circumferential
